Quality Management in Healthcare

Before I launch into my blog post for this week, which will be focused on quality management within healthcare, I want to quickly share why this topic is so important to me. In high school, I had major surgery to remove my right ovary, which was housing a malignant tumor. Some parts of my patient experience were good and others weren't, but my care overall was above average. I had a good doctor within a reputable hospital chain (UPMC), and since the surgery, I have been as healthy as a horse. However, I know not all patients receive the same quality of medical care - it's not as standardized as people think.

In my Health Systems class on Tuesday, my professor talked about measuring quality within the healthcare sector. Essentially, it boils down to one basic idea - if you improve quality, you improve outcomes. Pretty easy, right?

Nope.

In reality, there are a lot of factors that affect the quality of healthcare a patient receives, but I am going to focus on one in particular - treatment decisions - which I think is arguably the most important. It seems ridiculous that this could be a huge factor in quality differences, since all doctors are taught in medical school which treatments go with what diseases. In theory, treatment decisions should always be the same. However, variations in treatment are surprisingly common. A landmark study found that Americans receive recommended care only 55% of the time (Jim Jordan). To me, that's just insane.

The variation in care links back to a concept in one of the readings for this week called conformance quality. Obviously, there is a conformance quality issue within the healthcare system in the U.S. if only 55% of patients are receiving the proper treatment for their illness. For epithelial ovarian cancer, for example, the standard treatment is a mixture of two IV chemotherapy drugs - carboplatin and Taxol - given every 3-4 weeks. This treatment is the standard that all hospitals need to achieve if they want to attain high conformance quality for epithelial ovarian cancer treatment in general. Doctors that don't prescribe that treatment have low conformance quality.

Tolerances also shed light on this issue. In the reading, tolerances are essentially defined as "allowed deviations from the target." The target here is to treat everyone with the recommended care in order to achieve positive outcomes. But, going back to my ovarian cancer example, there are acceptable tolerances when it comes to treatment. For instance, I never had chemotherapy. My oncologist said that since I had low stage disease, chemotherapy would actually do severe damage the one ovary I had left without really "curing"me anymore than surgery already did. That's acceptable since I'm still healthy, even though I didn't follow the standard treatment. Harmful tolerances occur when physicians make abnormal treatment decisions based on misconceptions or outdated practices that hurt the patient, and the doctors are not held accountable. Since some dangerous deviations in treatment are not brought to light, the medical community is, in essence, treating them as tolerances. Those mistakes that are punished are often done so by a patient through a malpractice lawsuit - those would not be labelled a "tolerance" in theory. Since most people won't file a malpractice lawsuit, however, the threat of consequences is not great enough for some doctors, who continue to give off-the-wall treatments to their patients. So, unpunished, harmful deviations from standard care - or tolerances - persist at the patient's expense.

To conclude, variations in treatment decisions are important to consider when thinking about quality management in healthcare.  Some deviations from the standard regimen of care are justified, while others are based on faulty logic or outdated beliefs. Differentiated treatment plans affect doctor and hospital conformance quality standards negatively because they aren't conforming to the usual guidelines of care. Tolerances, in theory, occur in healthcare when 1) a physician does something unorthodox to the benefit of the patient, or when 2) a physician does something unorthodox that harms the patient, and it goes unpunished. Understanding both of these supply chain concepts will help healthcare executives and administrators balance quality rankings with the best interest of the patient, since sometimes they aren't parallel. So, how would you juggle these different aspects of healthcare quality?

Sources:

Jim Jordan's slides for lecture #2 in Health Systems for Mini 1, fall 2014